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GOOD DAY!
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T/C Cerebroscular Accident Probable
Infarct Right, Diabetes
Mellitus Type 2
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I. INTRODUCTION
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BACKGROUND OF THE STUDYThere are 18.2 million people in the United States
who have diabetes mellitus (DM). The prevalence of thismedical disorder increases with age. Half of all casesoccur in people over the age of 55, and it is estimatedthat 18% of the United States population over the age of
60 have DM. Patients with DM are more prone todevelop vascular diseases, including strokes. In additionto being a deadly disorder in diabetics, stroke is adisabling disorder. Most stroke survivors are left with
some physical and/or cognitive deficits. Stroke is theleading cause of permanent disability in the UnitedStates and it is the second leading cause of cognitivedecline. Thus healthcare providers who care for patientswith DM should be knowledgeable about the inter-
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relationship between DM and stroke, as well asinterventions that can minimize their patients’ risk of
primary and secondary stroke. In this article we willdiscuss epidemiologic relationships between DM andstroke, effects of DM on outcome from stroke, andstroke prevention strategies for the diabetic patient.
(Nader Antonios, MD and Scott Silliman, MD. DiabetesMellitus and Stroke.http://www.dcmsonline.org)
A person with diabetes is at higher risk thanothers for stroke and other cardiovascular diseases. Aswith many of the health problems associated withdiabetes, higher-than-normal blood glucose (bloodsugar) levels are factors.(www.ask.com)
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A. RATIONALE FOR
CHOOSING THE CASEThe case was studied for the following reasons:1. To have critical thinking skills necessary for
providing safe and effective nursing care.
2. To have a comprehensive assessment andimplement care base on our knowledge andskills of the condition
3. To familiarize ourselves with effective inter-
personal skills to emphasized health promotionand illness prevention.4. To impart the learning experience from direct
patient care.
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B. OBJECTIVES OF THE
STUDYThe presenters aim to recognize theactual and probable health problems of
the client in relation to his healthpractices as an individual andunderstand fully the process of the
occurrence of this disease throughapplying the theoretical frameworks andthe nursing processes.
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Specific ObjectivesAfter the completion of the study, a nurse shallbe able to:
1.To thoroughly assess the clinical manifestations of
patient with CVA based on the patient’s history.2.To formulate comprehensive nursing diagnosis for
a client with CVA.
3.To formulate a plan of care for patients with CVA.4.To formulate appropriate nursing interventions that
can be applied for a patient with CVA.
5.To evaluate the plan of care for a patient with CVA
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II. ASSESSMENT
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A. Client Profile NAME: J.M.
AGE: 50 years old
GENDER: Male
ADDRESS: Mandaluyong City
BIRTH DATE: October 28, 1961
NATIONALITY: Filipino
RELIGION: Roman Catholic CIVIL STATUS: Married
OCCUPATION: Retired taxi driver (2004-2011)
HEALTH CARE FINANCING: Fortune Health Insurance
ADMISSION DATE: August 13,2012 ADMISSION TIME: 11:55 AM
ADMITTING PHYSICIAN: Dr. Estacion
ADMITTING DIAGNOSIS: T/C Cerebrovascular Accident ProbableInfarct Right Diabetes Mellitus Type 2
FINAL DIAGNOSIS:
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B. Chief Complaint“Nanghihina ang kaliwang bahagi ng katawan ko tapos di
ako makapagsalita ng ayos” as verbalized by the patient.
C. History of Present IllnessFew hours prior to admission, patient is having a left sided
body weakness associated with numbness. According to him, hesuddenly fell from his seat and couldn’t talk straight.
D. Past Medical HistoryLast 2011, he stated that he undergone an amputation ofhis left big toe because of diabetes and was prescribed with some
medications for 3months:> Apidra (fast acting, mealtime insulin)>Lantus (long-acting insulin)
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E. Personal HistoryLast 2002, the patient had a boils/abscess on his
back. He’s been wondering why it doesn’t heal andagonizing the pain for months. So he consulted a doctorand then tried to obtain a blood glucose test and theyfound out that the blood glucose level is high and
diagnosed to have Type 2 Diabetes Mellitus. Client wasnot aware of the signs and symptoms of diabetes since hebelieve that he is healthy. He was prescribed by hisdoctor an antibiotic only for the faster healing of hisboils/abscess. He stated that he also tried controlling hisfood intake by avoiding sugar rich and cholesterol richfood. But he failed to do regular exercise since he is a
taxi driver andwasn’t
able to manage his diet. And last2011, he got a blister on his left big toe and doesn’t heal
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E. Personal Historyagain until it became a wound. Then he consulted a
doctor and advised him that his left big toe should beamputated before the wound increase its size since he isdiabetic.
Visual problems were verbalized by the patient. Duringhis childhood when he was 10 years old, he stated thathe was bumped by a car and was hospitalized. Thepatient wasn’t able to recall his childhood illnesses.
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F. Family History of Illness
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Family History of Illness
interpretationThe figure is a 3rd generation family
history of illness. Patient’s grandfather on
both side died of old age. His grandmotheron the father side died of cancer of theglands and grandmother on the mother side
died because of DM complications. Hisfather was a heavy drinker and died with aliver cirrhosis disease and his mother passedaway because of kidney disease.
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G. Gordon’s Functional AssessmentHealth Perception and Management
efore Hospitalization During Hospitalization Client verbalizes that he has
been pampered starting when
his left big toe was amputatedthis year because of diabetes.
Last year, he and his wife
decided that he should stop from
working because he easily getstired. Whenever he feels sick he
treated it immediately by taking
OTC drugs for headache.
Client stated that he obediently
follow all the orders of the
doctors. He believes that doctors,nurses and other medical
members will help him for faster
recovery.
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G. Gordon’s Functional AssessmentNutritional – Metabolic
Before Hospitalization During Hospitalization Client stated that he eats
everything he wants and sees.
Often failed to follow his DMdiet. He eats 3 times a day with
3 cups of rice per meal. She
drinks 6-8glasses of water a
day.
Client stated that he has
difficulty eating since his left
side of the body is weak andhe can’t chew and swallow his
food properly. Still on DM diet
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G. Gordon’s Functional Assessment24 Hour Diet Recall
Meal Food Quantity Breakfast Suman 2 pieces
Water 1 glass (240 ml)
Lunch Rice ¾ cupPakbit 1 serving
Dinner Rice ½ cup
Adobong manok 1 serving
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G. Gordon’s Functional AssessmentElimination
Before Hospitalization During hospitalization
Client verbalizes that he
defecates three times a week formed and brown in color. He
voids 6-8 times a day with
yellowish in color.
Client stated that he defecates
once a day since admissionwith a semi-formed stool and
brown in color. He voids 4-5
times with yellowish color and
needs assistance when voiding.
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G. Gordon’s Functional AssessmentActivity – Exercise
Before Hospitalization During hospitalization
Client verbalizes that he lacks
exercise ever since he became
a taxi driver. He also added
that he easily gets tired with
shortness of breath.
Still he was not able to carry
out any other activities.
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G. Gordon’s Functional AssessmentSleep – Rest
Before Hospitalization During hospitalization
Client normally gets 6 hours
of continuous sleep. He stated
that he can consumed 4 cups
of coffee and it doesn’t affect
his sleeping pattern. He does
have difficulty in breathingwhen lying and he snores. He
sleeps in prone position.
He claimed that
hospitalization affect his
sleeping pattern. He sleeps in a
semi fowler’s position. He
stated that he doesn’t feels
rested after sleeping becauseof the environment.
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G. Gordon’s Functional AssessmentCognitive – Perceptual
Before Hospitalization During hospitalization
The client can remember
remote, immediate, and recent
memory when being asked. He
has no hearing problems. He is
able to follow instructions and
answer questions accordingly.But he has attention deficit
when being asked.
The client is aware about his
present situation but not that
knowledgeable about the
disease condition when being
asked. He also verbalized
decreased sensation anddoesn’t feel pain easily.
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G. Gordon’s Functional AssessmentSelf –Perception – Self – Concept
Before Hospitalization During hospitalization
Client claimed that he was
already satisfied with life prior
to hospitalization although he
is experiencing some signs and
symptoms.
He stated that his self esteem is
low because of his
hospitalization and his disease.
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G. Gordon’s Functional AssessmentRole – Relationship
Before Hospitalization During hospitalization
Client lives with his wife and four
children. Even before hospitalization
he stated that he is already unable tosupport his family in financial needs
since he decided and his wife to stop
working and just stay at home. His
wife is a public teacher and he feels
a bit sad because he can’t help in
financial needs. He and his wife
make the decision in the family. They
have open communication with each
other.
The client presently feels the
support of his family and he is
happy about it.
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G. Gordon’s Functional AssessmentSexuality – Reproductive
Before Hospitalization During hospitalization
The patient has 4 sons and he
also stated that they didn’t
practice family planning. Prior
to hospitalization, the client
verbalized impotence by
having lessened sensationduring intimacy.
He claimed that he lost his
sexual interest due to the
physical changes that he is
experiencing.
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G. Gordon’s Functional AssessmentCoping – Stress – Tolerance
Before Hospitalization During hospitalization
When he is tired, he sleeps for
him to rest and not to stress
himself. He stated that he is
not ill tempered and a happy
person.
Though he is in stressful state
because of his hospitalization
he just calm himself and take
his bed rest.
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G. Gordon’s Functional AssessmentValue – Belief
Before Hospitalization During hospitalization
Prior to hospitalization, client
admitted that he doesn’t go to
church.
When he was hospitalized, he
still prays and asks for God’s
protection despite of whathappened to him.
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H. Physical ExaminationGeneral Survey
Client is lying on bed, has a proportionate body built.Hygiene and grooming is unkempt and has acetonebreath. He has no signs of distress, cooperative, and a bitdifficulty in speaking but understandable.
Vital signs
His temperature is 36.4 °C axillary, blood pressure takenin supine position is 140/100 mmHg, Radial Pulse Rate
is 84 beats per minute , weak and Respiratory rate is 26cycles per minute in cheyne-stokes respiration.
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H. Physical ExaminationSkin
His skin is brown in color, rough and has poor skinturgor. Symmetry of color is uniform. Edema +2 ispresent on both feet, moderate pitting and indentationsubsides rapidly. Skin is moist and warm to touch.
Hair
His hair is evenly distributed, thick curly hair withflaking.
NailsHis nails are convex in curvature and angle withgrooves texture, nail bed color is pallor with intact
surrounding tissue. Capillary refill is delayed.
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H. Physical ExaminationSkull and face
His head is normocephalic and has negative masses.Asymmetrical facial gestures and facial movements.
Eye Structures and Visual Acuity
His eyebrows and eyelashes are evenly distributed,symmetrical eyelids with intact skin and 18 involuntaryblinks. He has pale conjunctiva, anicteric sclera, smoothand clear cornea. Pupils is black, Pupils, Equal, Round,
React to Light and Acommodation. Peripheral vision isintact, coordinated extraocular movement but hasdifficulty in reading newsprint.
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H. Physical ExaminationEars and Hearing
His external pinnae is uniform color with skin,symmetrical and firm. Ear canal has wet cerumen. It isnot tender and has no gross abnormalities. His externalear canal has no discharges. He has sluggish hearingacuity.
Nose and Sinuses
He has symmetrical nasolabial fold. His septum is in
midline, non-deviated and has no perforation. Itsmucosa is pinkish and has no discharges. It is bothpatent. He has symmetrical gross smell. Sinuses are nottender.
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H. Physical ExaminationMouth and Oropharynx
His lips are pale, dry and have no lesions. His tongue isdeviated with white coating. He has incomplete set ofteeth with a missing lower 1st premolar. There are nodentures, braces and retainers. Gums are red, palate,oropharynx and tonsils is light pink. Uvula is in midline.Gag reflex is intact.
Neck
His movement is coordinated with limited range ofmotion and unequal muscle strength. Lymph nodes arenot palpable. Trachea is in midline, thyroid glands andjugular veins are not visible and carotid pulse is
symmetrical. There are neither neck masses nor rigidity.
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H. Physical ExaminationThorax and Lungs
His inspiration/expiration ratio is 1:2, cheyne-strokesbreathing pattern. He has positive use of accessorymuscles and difficulty of breathing with abnormalsound on the left lower lung field. Shape is symmetrical,aligned spine, skin is smooth. Positive for crackles on theleft lower lung field.
Heart
He has normo dynamic precordium. There are neitherthrills nor heaves. Point of maximal impulse (PMI) andapical beat is located at the 5th intercostals space (ICS)left mid clavicular line (LMCL).
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H. Physical ExaminationBreast and Axilla
His breasts are symmetrical in size and shape. There isno gynecomastia. It has no lesions. It is smooth and non-tender. There are no retractions, dimplings and edema.
AbdomenHis abdomen is generally smooth. It is symmetricallyglobular and has no lesions. Bowel sounds arenormoactive and heard 12 times/minute. It is
tymphanitic upon percussion. There is no fluid wave.Genito-Urinary System
Client refused to have his genitalia examined. There is
no dysuria and oliguria.
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H. Physical ExaminationUpper and Lower Extremities
Muscle strength is unequal, tenderness in bones andjoints deformities.
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H. Physical ExaminationDate
Diagnostic
Test Indication Normal Values
Actual
Values
Clinical
Interpretation
8/13/12 Complete Blood
Count
(CBC)
CBC is orderedto determine
presence of
bleeding,
anemia and
evaluate fluid
volume
balance
Hemoglobin 140-180gm/L
93 Hemoglobin,Hematocrit and RBC
is decreased indicates
Anemia which can be
due to destruction of
blood cells internally
because of the
viscosity of the blood.
Diabetes mellitus
decreases RBC life-
span. Decreased in
haemoglobin
decreases the amount
of oxygen-carryingprotein causes to
have difficulty in
breathing which
manifest in the client.
WBC is within the
normal value.
Hematocrit 0.40-0.54 0.29
RBC 4.3-
6.2x106/µL
3.1
WBC 4.1-
10.9x103/µ
L
6.1
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